Monday, June 9, 2014

E/R Visits Up

One of the claims made in defense of Obamacare was that it was going to reduce medical costs because the uninsured would not need to be using emergency rooms for primary medical care as much.  Because they would have medical insurance, they would find primary care physicians and stop waiting for a medical problem to be an emergency, or close to it.  It is all very logical.  So why is it not working?  From the June 9, 2014 Kentucky Courier-Journal:
Nationally, nearly half of ER doctors responding to a recent poll by the American College of Emergency Physicians said they've seen more visits since Jan. 1, and nearly nine in 10 expect those visits to rise in the next three years. Mike Rust, president of the Kentucky Hospital Association, said members statewide describe the same trend.
Experts cite many reasons: A longstanding shortage of primary-care doctors leaves too few to handle all the newly insured patients. Some doctors won't accept Medicaid. And poor people often can't take time from work when most primary care offices are open, while ERs operate round-the-clock and by law must at least stabilize patients.
Plus, some patients who have been uninsured for years don't have regular doctors and are accustomed to using ERs, even though it is much more expensive. Others have let illnesses and injuries fester so long they have become emergencies.
Let me suggest a really ugly reason that no one wants to hear.  Part of why many poor people are poor is present-orientation: they never do today what can be put off until tomorrow.  Instead of flossing and brushing, it's easier just to wait until you need teeth pulled.  Instead of delaying gratification by saving up money, it's easier to buy the toys you want now and then worry about how to pay for health insurance, or groceries, or car repairs.  Cheetos for breakfast for your kids is a lot easier than going shopping with a plan for what your household needs to eat for the next few days.

Obviously, not everyone who is poor is in that condition because of present-orientation.  But present-orientation is a factor in a lot of really stupid behaviors.  If you search for "present-orientated individuals" in, you will find papers about unwillingness to use condoms (and thus higher risks of HIV), drug addiction, and risky driving, among others.

It is not a surprise that people who are present-oriented will not make an appointment to see a primary care physician after a couple of weeks of a hacking cough, but will then head off to the emergency room in the middle of the night when the misery gets really bad.  Perhaps this belief that an absence of insurance caused overuse of emergency rooms was just that: a belief.


  1. It is my understanding that poor people using emergency rooms for primary care is mostly a problem because they don't pay the resulting bills (meaning emergency room care has to be priced much higher than it would cost if everybody using it paid) not because this is a waste of resources. So moving them to the regular primary care system wouldn't actually save much.

  2. My experience in EMS reinforces your opinion. Often I'd respond to calls for people who had been seen in the ED and given a referral to a clinic for a follow up. Only they never went. Or they'd be seen and given a prescription for antibiotics or pain killers. Which they wouldn't bother to get filled.

    Once they got ill enough, they'd call 9-1-1 so that we could take them back to the ED and restart the cycle.

    Very few of my poor patients had primary care physicians despite the fact that most of them had Medicaid.